<img src="https://certify.alexametrics.com/atrk.gif?account=jmOuq1CJLq20jn" style="display:none" height="1" width="1" alt="">

Population health - a proactive strike on the age of NHS pressure

Written by Steve Marriott on 23-Jun-2018 07:57:59


Traditional primary care services are reactive. A patient feels unwell or experiences symptoms that cause them to visit their GP. During the patient consultation, the GP may make a diagnosis, request tests or refer to a specialist. We accept this approach to healthcare, but with the pressures facing the NHS, we should be looking for alternatives.

The care process begins when the patient goes to see their doctor. We all have varying thresholds about when we decide to visit our GP. Some of us will go at the slightest hint of a problem, and others will leave it way too long. If a patient has a long-term condition, it would be better for them to see a doctor sooner rather than later:

  • care can begin sooner
  • the extent of treatment may be lower
  • in some cases, you can prevent unnecessary worsening or complications

The patient is not in pain or poor health for as long, and treatment regimes may be shorter. The patient experience improves. As a consequence, pressure on the NHS is lower, and the long-term cost of care reduces.

Public health campaigns can encourage patients to take action sooner, but there are challenges:

  1. it's difficult to target campaigns at specific groups of people
  2. mass marketing to the general public is costly
  3. we switch off when a message is not relevant, so it only hits home with people that may be deciding whether to see their GP or not at that specific time

Be proactive

What if you could get your entire population in one place and identify the people at risk of developing long-term conditions? You could offer proactive care to:

  • diagnose earlier
  • prevent long-term conditions from developing
  • slow down or stop the worsening of chronic diseases
  • target health improvement activities at the right people
  • involve patients in their care and increase confidence to self-manage

There is a way you can do this with modern technology. It's called population health. Vision's population health software is Outcomes Manager. There are three stages: collect, analyse, influence change.


We talk to your clinicians to understand your local healthcare challenges. As an example, let's say you're aware your prevalence is lower than in similar areas and need to identify patients with undiagnosed long-term conditions. We'd work with you to construct scenarios for each condition. The parameters for a potential undiagnosed person with diabetes would include:

  • their HbA1c results
  • other specific blood tests
  • the Leicester Diabetes Risk Score

For a likely COPD patient, the criteria are more speculative. We would take an interest in:

  • their age
  • smoking status
  • recent prescriptions for an inhaler or antibiotics for a chest infection

All this information is available, but it's locked away in the medical records within your GPs' IT systems. Taking this data and consolidating it within a central database enables you to analyse the health of your whole population.

We can extract the relevant data from the major GP IT systems for you. With daily extractions, you can be confident in the accuracy of the data because you're working with up-to-the-minute information.

At this point, we're not identifying patients nor extracting sensitive healthcare details. It's enough to maintain a count of how many patients meet the chosen parameters.


Outcomes Manager includes a web-based analytics dashboard. You can use this to explore the collated data and build meaningful insights. Using our example, you would see how many patients meet the criteria and might have undiagnosed diabetes or COPD. At this point, you won't be able to identify the patients, but you can see who their registered GP is.

Influence change

Each GP practice receives a matching report showing the information for its patients. These reports show GPs those patients who match the criteria. Practice staff can invite these patients to visit their doctor for a review. Additionally, doctors will see an alert when they are with a patient that meets the criteria, so they know to action a review. They can also access local templates, helping to standardise care across clinicians.

Click to download Greenwich CCG case study

Infinite possibilities

There's much more to population health than case finding. You can use it to address many healthcare challenges including:

  1. NHS health checks
  2. disease management
  3. improving care for specific patient cohorts
  4. identifying opportunities to improve access to healthcare services
  5. service utilisation

Transforming primary care with population health

On Tuesday 3 July, The King's Fund hosted an online event titled 'Transforming primary care with population health: moving to an outcomes-based model'. The speakers included Vision's Chief Medical Officer, Dr Jonathan Behr.

To register to catch-up on demand, visit The Kings Fund website.

Transforming primary care with population health

Topics: Population Level Healthcare, Intelligent healthcare, Cancer, outcomes manager, healthcare management


Search Vision

Vision UX eBook

Recent Posts